Medical training in the UK

D Stewart

doi:10.1136/adc.88.8.655

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Medical training in the UK

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Authors response
David Stewart
Published on: 22 March 2016
Medical Training in the UK
Patricia A Hamilton
Published on: 22 March 2016
Changes in education - stimulation, rather than simulation
Kentigern Thorburn
Published on: 22 March 2016
Re-focussing training
Megan Smith
Published on: 22 March 2016
Training the trainees
Dr Gautam Kulkarni
Published on: 22 March 2016
Author's reply to Winrow
David Stewart
Published on: 22 March 2016
The problem is greater than PICU training
Andrew P Winrow
Published on: 22 March 2016

Published on: 22 March 2016
Authors response
- David Stewart, Consultant Paediatric Intensivist
Dear Editor
It is encouraging that the Royal College supports the notion that "the general paediatrician remains core to the resuscitation and stabilisation of the critically ill child" and "exposure to critically ill patients is an essential part of training", and I am glad they seek to challenge the solutions proposed. However, to dismiss them as simply unrealistic fails to heed their own goal of more imaginative...
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Dear Editor
It is encouraging that the Royal College supports the notion that "the general paediatrician remains core to the resuscitation and stabilisation of the critically ill child" and "exposure to critically ill patients is an essential part of training", and I am glad they seek to challenge the solutions proposed. However, to dismiss them as simply unrealistic fails to heed their own goal of more imaginative teaching.
Whilst I can understand the comment, "all specialists feel theirs is essential", what is their basis for distinguishing the need for neonatal intensive care as compulsory and paediatric intensive care as not, especially now that learning opportunities for dealing with critically ill children have been so diminished by the centralization of critical care facilities? It also is somewhat paradoxical that they support the General Paediatrician as core to the resuscitation and stabilization of critically ill children, and feel a two day course is sufficient training, but demand a clinical attachment in community medicine?
I also am pleased that they support the use of simulation technology and agree that it is imperfect and expensive. It is, however, of sufficient functionality that it has a role as has been demonstrated in other countries, and hope that their comment indicating they should press for more funding is translated into action. Simulations use in addressing human factor error control is, of itself a way to deal with the exponential rise in legal costs the health service is facing, a major cause for which is human error. This alone could justify the Government providing additional funds for the proposed system. Its use to develop safer systems of operation is as useful as its use in managing the difficult airway in financial and human terms.
I applaud the attempts to introduce competence based education rather than time based, but will be interested to see how they will both define and assess these competencies. I look forward to seeing the development the Royal Colleges promise, and hope that they will be supportive when colleagues answer their call to provide inventive ways in which to deal with the training dilemma rather than dismissive.
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Medical Training in the UK
- Patricia A Hamilton, Vice President Training & Assessment
- Other Contributors:
  Mary E. McGraw, The Officer for Higher Specialist Training
Dear Editor
Re: Medical Training in the UK
We read the article by Dr Stewart with interest.[1] Whilst we support Dr Stewart’s statements “the general paediatrician remains core to the resuscitation and stabilisation of the critically ill child” and “exposure to critically ill patients is an essential part of training”, we wish to challenge his solutions.
The apprenticeship concept is diffic...
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Dear Editor
Re: Medical Training in the UK
We read the article by Dr Stewart with interest.[1] Whilst we support Dr Stewart’s statements “the general paediatrician remains core to the resuscitation and stabilisation of the critically ill child” and “exposure to critically ill patients is an essential part of training”, we wish to challenge his solutions.
The apprenticeship concept is difficult to deliver within the time constraints of working and training today - we should aim for more imaginative teaching (COPMED 2002).[2] Whilst every specialist considers that training in their subspecialty should be compulsory, solutions to designing effective teaching are not likely to be found in the creation of mandatory rotations though all specialist areas but in utilising the educational opportunities of all clinical encounters whenever they occur.
We recognise that encountering the critically ill child is an uncommon event and we strongly support the concept that all trainees undertake advanced Paediatric and Neonatal Life Support Courses. There are however also proposals for courses on Child Protection, Psychology, Human Rights, Epilepsy, Child Development, Nutrition and many more. Six to 12 months’ exposure to paediatric intensive care would take more time than the average trainee has to spare and it would be impossible to arrange rotations for all trainees. Simulators should indeed have their place in future education. At the present time, however, they are expensive and access to them is limited – we should press for more funding to be made available for educational purposes.
The College is defining competencies that Paediatricians need to acquire and is also developing more robust ways of assessing performance. Both will include the recognition and early management of the critically ill child. These will be key not only to assessing trainees but also to evaluating how training programmes deliver standards. The College has begun to run courses for Paediatricians as Educators, which will help to demonstrate ways in which creative use of time and opportunity can be integrated into a comprehensive education programme. We hope that colleagues will take advantage of these and let us know of inventive ways in which they have addressed the training dilemma.
References
(1) Stewart D. Medical training in the UK. Arch Dis Child 2003;88:655-658.
(2) COPMED Liberating Learning: A practical guide for learners and teachers to postgraduate medical education and the European Working Time Directive. 2002.
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Changes in education - stimulation, rather than simulation
- Kentigern Thorburn, Consultant in Paediatric Intensive Care
- Other Contributors:
  Andrew Durward, London, UK; Ian Michelow, Boston, USA; Beyers Oosthuizen, Cape Town, South Africa; Kevin Roman, Toronto, Canada
Dear Editor
Dr Stewart in his leading article, “Medical training in the UK”, rightly expressed concern regarding postgraduate specialist training in paediatrics in the UK.[1] He highlights diminishing duration of training and stagnation in educational methods (dare we interpose educationalists’ mindset) as major aetiologies for looming deficiencies. Having benefited from a well-rounded formulated paediatric spec...
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Dear Editor
Dr Stewart in his leading article, “Medical training in the UK”, rightly expressed concern regarding postgraduate specialist training in paediatrics in the UK.[1] He highlights diminishing duration of training and stagnation in educational methods (dare we interpose educationalists’ mindset) as major aetiologies for looming deficiencies. Having benefited from a well-rounded formulated paediatric specialist education, which included a mandatory rotation through the paediatric intensive care unit (PICU), along with completion of general paediatric training before any subspecialisation, we advocate this approach strongly. It certainly has succoured us well on different continents.
Without exposure to PICU and/or Paediatric Accident and Emergency (A&E), where do the present paediatric trainees in the UK tangibly master care of the seriously ill child? Hopefully not entirely in the Labour Ward or while awaiting the occasional retrieval. Training time spent in the PICU has distinct educational advantages for paediatric specialist training:[1] there is a high incidence of one-to-one teaching every working day (i.e. every day);[2] intensivists are committed educationalists (not only out of necessity);[3] there is a high degree of clinical exposure where recognition and assessment of critical illness is learnt and honed (ask any registrar who has rotated through a PICU);[4] there is no place to hide – ‘your patients’ are clearly defined;[5] management of basic life support skills, such as gaining competency in airway management, assessing sustainable respiration and effective cardiac output, is achieved;[6] acquired skills build on the foundation of previously-received APLS training;[7] “competence-based” assessment is inherent.
It is easier to evangalise about adjusting rotations than to effect that change. The ‘spaces’ available and those outposts needing to be filled rather than the best educational interests of the trainee(s) often govern rotations. The RCPCH may dictate training policy, but it does not fund local education or pay the trainees’ salaries. Additionally, some PICU directors may resist the imposition of a steady stream of reluctant PICU middle-graders, but the interests of children (the primary recipients of a good paediatric training scheme) need to be heeded.
Remote learning cannot substitute for direct bedside teaching and simulation techniques have been shown to be deficient(2). Paediatric trainees need real-life guidance through the subtle and dynamic challenges of clinical medicine. In our experience, there is no formula to teach ‘judgement’ in clinical decision making apart from first-hand experience under the guidance of a discerning teacher. We would advocate readjusting paediatric training rotations to include this hands-on real-life experience with critically ill children, long before breeding Consultants in Critical Simulation Care. With a structured teaching program and a logbook to ensure that all important aspects are covered, a 6-month rotation in PICU would suffice.
A central issue is whether you consider recognition of serious illness, resuscitation and stabilisation of critically ill children, and acute management of life-threatening conditions as basic, generic skills required for a specialist paediatric trainee and a general paediatrician. Would you prefer your own seriously ill child to present to a district general hospital where all the paediatric staff have these skills, or not?
References
(1) Stewart D. Medical training in the UK. Arch Dis Child 2003;88:655-8.
(2) Olympio MA, Whelan R, Ford RP, Saunders IC. Failure of simulation training to change residents’ management of oesophageal intubation. Br J Anaesth 2003;91:312-8.
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Re-focussing training
- Megan Smith, Fellow in Paediatric Critical Care
Dear Editor
The reflections of Stewart on the state of training for general paediatricians in the acute stabilization of critically ill children will hopefully fuel much needed debate and change. Whilst agreeing with the many shortfalls of the current system which he identifies, however, I believe that the solution should not be focussed around the paediatric intensive care unit (PICU).
The majority of r...
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Dear Editor
The reflections of Stewart on the state of training for general paediatricians in the acute stabilization of critically ill children will hopefully fuel much needed debate and change. Whilst agreeing with the many shortfalls of the current system which he identifies, however, I believe that the solution should not be focussed around the paediatric intensive care unit (PICU).
The majority of resuscitation and stabilization of children happens outside the PICU. My experience of talking to general paediatricians is that the increasing emphasis on tertiary intensive care units makes them feel increasingly deskilled, as opposed to enhancing their training opportunities and support. Rather than deskilling paediatricians, their specialist local expertise should be enhanced, encouraged and acknowledged.
Acute Paediatrics, as practiced in a District General Hospital (DGH), is different in context, resources and management goals from that practiced on the tertiary PICU. By definition, intensivists see children who have been assessed as being critically ill by another clinician. The general paediatrician has to decide who, amongst the many children they see, should be brought to the attention of an intensivist. The intensivist is accustomed to managing crisis situations with a full array of back-up both in terms of equipment and personnel. The general paediatrician has to work within the constraints of limited local resources and be able to utilize them to their maximum potential. Stabilization and timely transfer (if required) are the goals of care in the district hospital, whereas in focus on the intensive care unit moves to ongoing physiological support and medium-term management to optimise outcome.
The validity of acute paediatrics as a special interest for the general paediatrician has been affirmed by the growing number of posts advertised for paediatricians with an interest in emergency medicine, or able to take on a liaison role with the Emergency Department. As this area of interest develops further, these paediatricians will be best placed to provide training both for Senior House Officers (SHOs) and Specialist Registrars (SpRs) and also their other consultant colleagues. They will also be in a position to facilitate more effective multi-disciplinary training, with local Emergency Medicine and Anaesthesia staff, and to work around local logistical issues. 6 months of PICU training may be of interest to some, but will not necessarily expose the trainee to situations similar to those that they will face as a general paediatrician. The north American practice of rotation through the PICU for 1 or 2 months during residency may provide enough exposure at an SHO level for the trainee to assimilate some foundational principles and identify some of their own ongoing learning needs. As the length of training shortens, it is crucial to distil those aspects of experience and skill acquisition that an SpR would hope to gain from PICU placement into a more focussed form. The use of technology, such as simulators, and audio-visual feedback in the local context certainly has potential to do this. As Stewart points out, the growing use of telemedicine does allow the tertiary intensivist to collaborate as a part of the medical team in acute settings in the DGH, usually prior to then retrieving the child. As local training would need to involve all team members, the intensivist does have a role to play in this context. As local clinicians identify their training needs, intensivists may well be invited to offer specific expertise, but should not drive the educational agenda.
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Training the trainees
- Dr Gautam Kulkarni, SHO PICU, St Marys Hospital, London
Dear Editor
As a junior doctor in training, I can’t agree more strongly with Dr Stewart.[1] I am presently a senior house officer in Paediatric Intensive care and I feel strongly that all junior doctors should have an opportunity to work in an Intensive care unit. This is regardless of whether they view themselves as intensivists or general paediatricians in the long run.
In my opinion training course...
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Dear Editor
As a junior doctor in training, I can’t agree more strongly with Dr Stewart.[1] I am presently a senior house officer in Paediatric Intensive care and I feel strongly that all junior doctors should have an opportunity to work in an Intensive care unit. This is regardless of whether they view themselves as intensivists or general paediatricians in the long run.
In my opinion training courses such as APLS and NALS are brilliant when a structured approach is needed for an acutely unwell infant or child. However intensive care training makes one extremely meticulous when monitoring simple trends such as fluid balance, urine output and vital parameters. Personally I hope this training would help me in the future to anticipate worrying trends in my patients even before things get seriously wrong. In addition intensive care units are an excellent model for the full shift system and train doctors in systematic handovers.
At a SHO level, there are very few training posts in paediatric Intensive care. At the same time it would be quite intimidating and unsettling to work as a registrar in Intensive care with no prior training. Centralisation of intensive care units inadvertently leads to other units having a low threshold for transferring patients. While stabilising the sick child is a priority task, there are often too many people at hand (including registrars and consultants in A&E, paediatrics and anaesthesia) playing a vital role. The poor SHO in paediatrics is often out of all the “action.”
Hands on experience is essential between APLS and NALS courses which are repeated every 3 years. Are mannequins and simulators an acceptable alternative?
Reference
(1) Stewart D. Medical training in the UK. Arch Dis Child 2003;88:655-658 .
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Author's reply to Winrow
- David Stewart, Consultant Paediatric Intensivist
Dear Editor
My thanks to Dr Winrow for pointing out that all disciplines are affected by the contraction of training time.[1] Consultants all over the country are struggling to maintain the standards of care for the future in the face of increasing demands on their own time and reduced time in which to train.
However, rather than obscure the wider issue I hope to draw attention to it. This issue affect...
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Dear Editor
My thanks to Dr Winrow for pointing out that all disciplines are affected by the contraction of training time.[1] Consultants all over the country are struggling to maintain the standards of care for the future in the face of increasing demands on their own time and reduced time in which to train.
However, rather than obscure the wider issue I hope to draw attention to it. This issue affects us all. The rotation of trainees through intensive care is not a compartmentalisation of training as the experience is applicable to all trainees, and also addresses the loss of continuity with the sickest of patients that Dr Winrow refers to.
Whilst the issue of continuity of care in its widest sense is a major one, affecting PICU as much as general paediatrics, the comment that the initial resuscitation of critically ill patients is “the easy bit” and that certification in PALS or APLS is sufficient must be a reference to how “easy” it is to get wrong. Inefficient resuscitation has far reaching consequences on patient outcome, which, of course, the referring team does not see as the patients are taken away by the retrieval team.
The introduction of simulation centres is not a cure-all. However, it is a component of a strategy to improve the efficiency of training. The Human Patient Simulator is appropriate for Critical Care, but the educational approach can assist in training all future doctors. Unfortunately, most physicians are not aware of what is available. The simulated patient (both mannequin and computer based) can enhance (not replace) “real” clinical experience, and can even be used to assist in obtaining the longitudinal experience Dr Winrow feels is being lost. Our options are limited, either the duration of training is extended once more, or we seek alternatives to improve educational efficiency. The use of technology can be a useful aid in improving our use of time. If implemented correctly, it may redress the balance between time available, and the need for clinical excellence. It may however, require a new way of thinking about medical education.
Reference
(1) Winrow AP. The problem is greater than PICU training [electronic response to Stewart D, Medical training in the UK] archdischild.com 2003 http://adc.bmjjournals.com/cgi/eletters/archdischild;88/8/655#522
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
The problem is greater than PICU training
- Andrew P Winrow, Consultant Paediatrician
Dear Editor
Whilst I agree with much of what Stewart discusses, his leading article is at danger of obscuring a wider malaise in training by its call for all trainees to experience and, by extension, staff regional PICUs.[1] Potentially every specialty within Paediatrics could add its voice in this way resulting in the compartmentalisation of training.
Consultants working in district general hospitals recogn...
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Dear Editor
Whilst I agree with much of what Stewart discusses, his leading article is at danger of obscuring a wider malaise in training by its call for all trainees to experience and, by extension, staff regional PICUs.[1] Potentially every specialty within Paediatrics could add its voice in this way resulting in the compartmentalisation of training.
Consultants working in district general hospitals recognise that many PICU patients originate in their hospitals and are then transferred to the PICUs. Paediatric trainees in the DGH therefore do have the chance to experience the recognition and supervised stabilisation of sick patients prior to retrieval to the PICU. In my experience most paediatric trainees have already undergone a plethora of certificated courses of the PALS, NALS and APLS variety and are therefore well versed in the mantra espoused on these courses. This is the "easy bit".
A more pressing problem in the debate surrounding education is how we can train future consultant colleagues during their Specialist Registrar years in the aspects of patient management that extend beyond the end of their shift. It is more than a loss of continuity of patient care. The chance to experience and understand the totality of patient care, whether in-patient or outpatient, has been lost. Trainees largely see cross-sectional fragments of care but rarely the longitudinal aspects. The damage inflicted by the New Deal has been a loss of cumulative experience. Experience is difficult to obtain from study days. No amount of clinical simulators will confer such everyday clinical experience and real life decision making. Current medical education fails the trainees by preventing the acquisition of experience derived from shouldering supervised clinical responsibility, which equips us for the "now what do I do" part of medicine.
Reference
(1) Stewart D. Medical training in the UK. Arch Dis Child 2003;88:655-658.
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Conflict of Interest:
None declared.
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